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Dancetherapy in autism: a case report

ARTICLE JUNE 2015

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Lavinia Teixeira-Machado
Universidade Federal de Sergipe
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205

Dance therapy in autism: a case report

Danaterapia no autismo: um estudo de caso

La danzaterapia para el autismo: estudio experimental

Lavinia Teixeira-Machado1

ABSTRACT | Autism is one of the most common

de vida de um adolescente com autismo. Trata-se de um

neurological disorders that affects the neurological

estudo de caso de um jovem com 15 anos de idade, que

development of children. Therapeutic interventions may

participou de 120 sesses de danaterapia, com durao

intervene in communication disorders and stereotyped

de 30 minutos, duas vezes por semana em dias alternados,

behaviors such as dancing, which as therapy can activate

durante um ano. Os instrumentos de avaliao utilizados

sensory pathways that enable gesture improvement. This

foram a Medida da Funo Motora (MFM), Teste de Tinetti e

study aimed to observe the effects of dance therapy in

Escala de Avaliao do Autismo Infantil (Childhood Autism

motor performance and gesture, body balance and gait,

Rating Scale CARS). Segundo a MFM, o escore total

as well as in the quality of life of an adolescent with

aumentou 27,08%; o Teste de Tinetti referente ao equilbrio

autistic disorder. It is a case study of a fifteen-year-old

aumentou de 68 para 75% e a marcha de 16% para 66%; o

male who participated in 120 sessions of dance therapy,

CARS foi alterado de 41,5 para 34 pontos, transferindo o

lasting 30 minutes, twice a week, on alternate days, over

transtorno de grave para moderado dentro dos parmetros

a period of one year. The assessment instruments used

propostos. A danaterapia pode otimizar o comportamento

were the Motor Function Measure (MFM), Tinetti test and

neuropsicomotor de jovens com transtornos autistas.

Childhood Autism Rating Scale (CARS). According to the

Descritores | Transtorno Autstico; Terapia atravs da

MFM, the total score increased 27.08%; the Tinetti test

Dana; Marcha, Terapias Complementares; Destreza

regarding balance increased from 68 to 75%, and gait,

Motora.

CASE STUDY

DOI: 10.590/1809-2950/11137322022015

from 16% to 66%. CARS changed from 41.5 to 34 points,

changing the severe disorder to moderate within the

RESUMEN | El autismo es uno de los trastornos neurolgicos

proposed parameters. The dance therapy can optimize

ms comunes que afectan al desarrollo neurolgico y

the psychomotor behavior of young people with autistic

psicomotor de nios. Diversas intervenciones teraputicas

disorders.

pueden intervenir en las desordenes de la comunicacin y

Keywords | Autistic Disorder; Dance Therapy; Gait;

en las conductas estereotipadas, tales como la danza, que

Complementary Therapies; Motor Skills

como terapia puede activar la sensorialidad permitiendo

la mejora del gesto. En este estudio se busc observar los

RESUMO | O autismo uma das desordens neurolgicas

efectos de la danzaterapia al desempeo motor y del gesto,

mais

desenvolvimento

al equilibrio del cuerpo y de la marcha, as como a la calidad

neuropsicomotor de crianas. Intervenes teraputicas

de vida de un adolescente autista. Se trata de un estudio

podem intervir nos transtornos de comunicao e nos

experimental con un joven de 15 aos de edad, el cual particip

comportamentos estereotipados, desse modo a dana,

de 120 sesiones de danzaterapia, con duracin media de

como terapia, pode ativar vias sensoriais que viabilizam o

30 minutos, llevada a cabo dos veces por semana en das

aprimoramento do gesto. Este estudo visou observar os

distintos, durante un ao. Se utilizaron los instrumentos: la

efeitos da danaterapia no desempenho motor e gestual,

Medida de la Funcin Motora (MFM), la Prueba de Tinetti y la

no equilbrio corporal e na marcha, bem como na qualidade

Escala de Evaluacin del Autismo Infantil (Childhood Autism

comuns

que

afetam

This study was developed in Academia Sergipana de Ballet Aracaju (SE), Brazil.
1
Assistant Professor in the Science Education Department in Universidade Federal de Sergipe So Cristovo (SE) Brazil.

Mailing address: Lavinia Teixeira-Machado Rua Dom Jos Thomaz, 442 So Jos CEP: 49015-090 Aracaju (SE), Brazil. E-mail: lavinia@ufs.br/laviniateixeira@infonet.com.br/
ltamachado@hotmail.com Presentation: Feb. 2013 Accepted for publication: Mar. 2015 Approval from the Ethics Committee of Universidade Federal de Sergipe under
CAAE protocol no. 02238312.2.0000.0058/12

205

Fisioter Pesq. 2015;22(2):205-211

Rating Scale - CARS). De acuerdo a la MFM la puntuacin total

puede optimizar la conducta neurolgica y psicomotora del joven

aument un 27,08%; la Prueba de Tinetti con respeto al equilibrio

con trastornos autsticos.no hay comprobacin suficiente sobre la

aument del 68% al 75% y la marcha del 16% al 66%; la CARS baj

eficacia de la VNI en el aumento de la tolerancia al ejercicio.

del 41,5 al 34 puntos, pasando la clasificacin del trastorno, segn los

Palabras clave | Trastorno Autstico; Terapia a travs de la Danza;

parmetros propuestos, de grave a moderado. As, la danzaterapia

Marcha; Terapias Complementarias; Destreza Motora

INTRODUCTION

Dance as a therapy may stimulate the integration

of sensation and perception, and, thus, predispose
action13,14. Coordinated activities are fundamentally
important for the progress of the neuromotor system10,15.
Motor therapy, when it is associated with music, may
make social interaction and communication easier16, as
well as several systems which interfere in the perception
of movement, and are fundamental for the socialemotional development and for the interconnection
of areas which are responsible for the association of
movement17-19.
Thus, this study proposes that dance and physical
therapy be united as a possibility to develop and modify an
array of irregular and uncoordinated movement patterns.
The lack of studies with the proposed design has inspired
a need for researching the effects which are caused by
dance in autistic peoples behavioral disorders through
teleceptive stimuli which are imposed by music and dance.
Therefore, this study seeks to observe the dance
therapy effects in a teenager with autistic disorders, to
evaluate motor and gesture performance in the autistic
spectrum through the motor function measure (MFM),
to analyze body balance and gait through Tinetti Test,
and to investigate the effects in the autistic teenagers
quality of life through the Childhood Autism Rating
Scale (CARS).

Autism spectrum disorder is one of the most common

neurological disorders affecting neuropsychomotor
development in children. This condition involves an array
of neurological, behavioral disorders with three most
evident factors: difficulty socializing, verbal and non-verbal
communication disorders, and repetitive, stereotyped
behavior patterns1,2. Moreover, autistic children have
significantly damaged imitation skills and spontaneous
use of descriptive gestures which prevent complex
behaviors and socialization from being achieved3,4.
A study that was conducted with purebred rats5
showed behavioral and social variations. Sensory
difficulty is considered as one of the central problems in
autism, as it is associated with barriers that are related
to socialization and communication, and to a restricted
repertoire of interests and activities6,7.
Autism is a disorder whose pathological base is
unknown. Ramachandran and Seckel8 explain that the
main damage may be in the mirror-neuron system.
Many cognitive neuroscience researchers consider that
system provides the psychological mechanism for the
interaction between perception and action. Mirror
neurons may be important to understand the actions
from other people, and to learn new motor acquisitions
through imitation. Problems in that system are the base
for cognitive disorders such as autism9.
Many autistic children have very early signs of
sensory and motor damage. Therapeutic interventions
which operate in the sensory stimuli have been found
to display positive effects, as well as visual and auditory
interventions, sensory-motor management techniques,
and physical exercises2,10,11.
Synchronous repetitive movements may improve
stimuli in the mirror-neuron system8. Pectrus, et al.2
praise physical therapy as critical to find ways which
can minimize neuromotor damage. Music and dance,
in turn, exist in all cultures and are part of a series of
creative behaviors12.
206

METHODOLOGY
This is the case report of a 15-year old male
individual, suffering from a pervasive developmental
disorder in the autistic spectrum. The youngster took
part in 120 dance therapy sessions of 30 minutes each,
twice a week, in different days, for a year. The teenagers
mother signed a Consent Form, agreeing with the
application of the protocol and the publication of
obtained images and data. The research was approved
by the Ethics Committee of Universidade Federal de
Sergipe.

Teixeira-Machado. Dance therapy in autism

The dance therapy sessions were conducted in a

proper dance classroom, with mirrors, parallel bars, and
sound equipment, at Academia Sergipana de Ballet, in
Aracaju, Sergipe. Session comprised laterality, musical,
and rhythmic perception tasks, with four series of eight
repetitions for the following activities: anteroposterior
and latero-lateral spreading of lower limbs; single-leg
and double-leg squatting; weight shifting; spinning;
anterior, lateral, and posterior gait. All activities are
associated with movements and waving of upper limbs
in ballroom dance styles. Choreographed sequences
were changed, along with songs, at every 20 sessions,
so that could result in changes in the teenagers routine.
The evaluation scales allow measuring the behaviors
from children with pervasive developmental disorders,
in a way to establish a more reliable diagnose20,21.
MFM was used in order to evaluate motor and gesture
performance, as it is a scale that comprises 32 static and
dynamic items and it measures examined peoples motor
skills. Items are tested in lying, sitting, or standing positions,
and they are divided in three dimensions: standing position
and shifting, with 13 items (D1); axial and proximal
motor skills, with 12 items (D2); distal motor skills, with
seven items (D3), six of which regarding the upper limbs.
Each item is classified in a four-point scale, as follows:
unable to start the task or maintain the initial position
(zero); performs the exercise partially (one); performs the
required movement partially or performs it completely,
albeit imperfectly (two) - offsetting, insufficient time
maintaining the position, slowness, lack of movement
control; performs the exercise completely and normally,
with a controlled, perfect, objective movement, at a
constant speed (three). The values in each dimension are:
D1, 39 points; D2, 36 points; D3, 21 points, the three
dimensions totaling 96 points22,24.
Tinneti test was applied in order to evaluate body
balance and gait abnormalities. The test consist of 16
items, of which nine regard body balance and seven
refer to gait. Tinneti test classifies gait aspects such as
speed, step distance, standing symmetry and balance,
spinning, and shifts with eyes shut. Counting for each
exercise ranges from 0 to 1, or from 0 to 2, with lower
numbers indicating poor physical skills. The total score
is the sum of scores for body and gait balance, and it
adds up to 28 points. Total score is broken down in 12
points for gait and 16 for body balance25.
In order to analyze the effects from aspects regarding
quality of life and severity of autism, CARS was used - it
is a 15-item scale which helps identify autistic children

and distinguishes them from non-autistic children with

developmental problems. Its importance consists of
identifying mild and moderate from severe autism. It is
brief, and its use is adequate for any child who is older than
two years of age. The results define the following scores:
15-30: non-autistic; 30-36: mild to moderate autism; 3660: severe autism26,27. CARS was used at four moments:
before the intervention, after a six-month intervention
period, after a twelve-month intervention period, and six
months after the intervention was finished, in order to
observe whether observed changes were going to last.
RESULTS
In the first evaluation, the teenager was found to have
a 41.5-point score, and he was classified as been severely
autistic, according to Pereira, et al.21. After a six-month
intervention, the teenagers score was 37.5 points,
and after twelve months of intervention, 32.5 points,
causing him to fall into the mild to moderate autism
classification. After twelve months of intervention, the
protocol was interrupted for six months, when data were
collected again, and those data showed the teenager
scored 34 points (Figure 1).

CARS
41.5
37.4

AV1

AV2

32.5

34

AV3

AV4

Figure 1. Values obtained through the Childhood Autism Rating

Scale (CARS). At the beginning of the protocol (AV1), after a
six-month intervention period (AV2), after a twelve-month
intervention period (AV3), and a follow-up six months after the
intervention was finished (AV4)

In the evaluation regarding the motor function, the data

before the study protocol was started (AV1) corresponded
to the following values: D1: 9 points (23.07%); D2: 18
(50%); D3: 4 (19.04%). The sum of all dimensions was 31
points (32.29 %). After six months of intervention, another
evaluation (AV2) was conducted, in which D1 reached 17
points (43.58%), D2, 24 (66.66%), and D3, 7 (33.33%),
totaling 48 points (50%). At the end of the intervention
207

Fisioter Pesq. 2015;22(2):205-211

protocol, another evaluation (AV3) was conducted, in

which D1 reached 21 points (53.84%), D2, 29 (80.55%),
and D3 was not found to have changed, maintaining 7
points (33.33%), totaling 57 points (59,37%). Figure
2 shows the values that were obtained for the three
dimensions at the moments of analysis and their respective
total scores, which point towards a more marked increase
in dimension 2 as compared to the remaining ones.
100

AV1

AV2

AV1

Score (%)

80

60

40

20

D1

D1

D1

D1

Motor Function Measure (MFM)

Figure 2. Values (%) of dimensions (D1, D2, D3 , and Total D) of

motor function measure (MFM). At the beginning of the protocol
(AV1), after a six-month intervention period (AV2), and after a
twelve-month intervention period (AV3)

Figure 3 shows data as obtained by Tinneti test. In the

first evaluation (AV1), the dimension regarding balance
revealed 11 points (68%), and the dimension regarding
gait, in turn, only 2 points (16%), which makes up 13 points
total (46%). After the six months (AV2), balance was
found to reach 11 points (68%), and gait, 3 points (25%).
The total was 14 points (50%). After the twelve monthintervention, the last analysis (AV3) was conducted, and
the obtained data were: balance - 12 points (75%); gait - 8
points (66%); total - 20 points (71%).

Tinetti Test

AV1

AV2

AV3

80
70
60
50
40
30
20
10
0

Balance

Gait

Total

Figure 3. Data regarding the application of Tinetti Test at the

beginning of the protocol (AV1), after a six-month intervention
period (AV2), and after a twelve-month intervention period (AV3)

208

DISCUSSION
The teenagers mother watched a public presentation
of the extension group from Universidade Federal de
Sergipe, comprising children and adolescents with
various disabilities. The mother was touched, and
she requested that her son be included in the dance
classes.
As soon as the boy signed up to the program, the
evaluation instruments were applied, and he was assessed
to need individual dance classes, to be included in the
group afterwards, thus preventing him to feel inhibited
or unable to perform the tasks that were proposed in
the group classes.
The results above corroborate the findings from
Weber and Newmark28 regarding the efficient use
of alternative and complementary therapies in the
autistic spectrum. Pectrus, et al.2 noted that sensorymotor treatments are used well beyond holistic
intervention plans, as alternative therapies seek to
improve performance considering sensory and motor
difficulties, including other essential components, such
as cognitive and psychosocial functions.
It is interesting to observe the data that were
obtained by CARS. The instrument assess factors that
are related to quality of life and to autistic spectrum
severity, and it encompasses issues concerning
personal relationships, use of the body, senses, and
objects, response to changes, verbal and non-verbal
communication, and cognitive consistency19,26.
The data obtained by MFM show that the
teenager had better results in the items corresponding
to dimension 2 (D2), which is related to axial and
proximal motor skills, including changes regarding
head directions - they are essential to guide the desired
movement10,18,19. There was little alteration in regards
to dimension 3 (D3), which involves distal motor skills
- encompassing the handling of objects, for example.
The teenagers muscles are atrophied for lack of use,
and the protocol involves global body movements.
Besides that, he had trouble following the requests to
execute the MFM tasks.
Autism leads to difficulties in the spontaneous process
regarding imitation and description of gestures4,29.
Dancing stimulates this spontaneous process from
symbolic frames of reference which are systematically
requested during classes. When they are needed in
other daily contexts, they are easily identified as learning
takes place2, and they are noticed in the significant

Teixeira-Machado. Dance therapy in autism

participation effects of autistic people in their social

contexts. Finally, the choreographed sequences were
modified at every 20 sessions, stimulating the symbolic
frames of reference from songs in association with
body movements. The teenager resisted strongly when
the first modification took place, but in the following
one he was already having fun with changes, as he
noticed he was capable of adapting to the alterations in
proposed sequences.
Dexterity and balance could be evaluated through
Tinneti test, especially in regards to gait quality25.
The youngster used to neglect the following gait and
walked in an asymmetric way, and that justifies the
better response in the score involving gait criteria, as
the teenager now executes the following gait fearlessly,
even though with some help.
The benefits from physical activity in this population
are widely documented in the literature4,11,17-19.
Dancing, as a physical activity, fosters the reduction
of atypical behaviors, as it physiologically modulates
stereotyped actions through the release of specific
neurotransmitters17-19. Such speculations generated
interest regarding the inclusion of regular physical
education in autism treatment2. Although that is a
result from the commitment level, it is plausible that
diminishing stereotyped behaviors may contribute for
autistic people to participate more in their environments,
in order to develop their skills.
The results from studies by Ingersoll, et al.4
reinforce the effectiveness of interventions including
natural movements for learning and imitating gestures.
Dancing really stimulates the imitation of gestures.
Despite the sensory alterations not being specifically
from autistic disorders, their prevalence is very high,
and Dawson and Watling29 mention the prevalence
of abnormalities in the sensory integration, and that
therapies which focus on approaching the training of
sensory integrations that are focused on the auditory
system may contribute to resolve abnormalities in the
autistic spectrum.
The replacement of bizarre and repetitive
movements that are peculiar to the autistic universe
predisposes the annulment of those stereotyped
behaviors, as those actions are performed with a
purpose. Therefore, the delayed behavioral maturity
may be reversed through the intervention of activities
which propose the integration of several attention
systems, so they can contribute to develop the social
communication ability in autistic people6.

Despite physical therapy using many exercises, it is

necessary to investigate their effects in the development
and in the application of proper treatments to the
autistic spectrum2. This case report is just a draft of
a therapeutic program which may contribute to the
investigations about the autistic spectrum. Our biggest
difficulty was to try and minimize the stereotyped
behavior, which interferes in the response actions from
other appropriate behaviors.
The sequences proposed in our study interfered in
these inadequate behaviors, above all. We used songs
with lyrics in order to imply meaning for specific
actions, and that substantially affected the following
stereotyped behaviors. Besides that, we contributed to
movement coordination and dexterity, as the data that
were obtained through MFM and Tinetti point out.
The scores obtained in CARS showed the reduction
of stereotyped movements in this teenager, as well as
issues regarding social interaction, even after the dance
therapy sessions had been finished.
The results that were obtained in this study
stress the fundamental importance of dance therapy
intervention in order to improve sensory-motor
function, thus allowing autistic individuals to
demonstrate their full cognitive, behavioral, social,
and communicative behaviors.
CONCLUSION
Dance therapy favored motor and gesture
performance, even in body balance and gait. Besides
that, it contributed to improve the quality of life of the
teenager with autistic spectrum.
Both his static and his dynamic motor skills were
improved, which demonstrates the importance of
the rhythmic movement in the development of the
motor skill that had been neglected due to the autistic
spectrum condition.
Body imbalance and gait abnormalities were
minimized in the teenager after the dance therapy
sessions, probably due to the stimuli that were proposed
by the dance, such as alternated exercises and various
directions.
Dance therapy also contributed greatly to the
improvement of quality of life and reduction of autistic
spectrum severity, which indicates the fundamental
importance of the application and participation in
projects of that profile, in order to foster substantial
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Fisioter Pesq. 2015;22(2):205-211

improvements in the disorders that were visualized in

the teenager who took part in this study.

7. Silva LM, Cignolini A, Warren R, Budden S, Skowron-Gooch,

A. Improvement in sensory impairment and social interaction
in young children with autism following treatment with an
original qigong massage methodology. Am J Chin Med.
2007;35(3):393-406.

CLINICAL IMPLICATIONS AND STUDY

LIMITATIONS

8. Ramachandran VS, Seckel EL. Synchronized dance therapy

to stimulate mirror neurons in autism. Med Hypotheses.
2011;76(1):150-1.

The study showed the importance of using dance

therapy, and how it can effectively operate in the autistic
spectrum disturbances. This pragmatic judgment can
only generate results that can be generalized in the
clinical practice through a study with a more robust
design.
In order to have that, a larger sample would be
needed, and so would the formation of two groups in
order to compare the effects from the interventions, to
check whether dance, as a therapy, can contribute to the
neuropsychomotor and quality of life enhancement in
the autistic spectrum.
Interventions which operate in various systems which
are based on rhythm and on dancing activities may be
used to alleviate social communication impairments, as
well as sensory, motor, and behavioral comorbidities in
autism. However, future research must extend this study
in order to examine the effects from the various systems
dance can intervene in, thus solidifying the findings in
this investigation.
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